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I’m voting yes

Donatello’s David. David took on Goliath and won! Imagine that!
Ohio has a rare opportunity to lower drug prices this November.

I’m voting Yes on Issue 2, even after seeing all the “No” ads that the drug companies run warning of dire consequences if we dare to demand that we should pay the same for drugs that the Veterans Administration pays.

TV commercial after TV commercial scaring us of excessive legal bills. As if, if the bill passes, the state of Ohio could be bought by PhRMA, since if the law does pass, PhRMA will surely be waging war. As if the voters who passed the law should have no rights in the legal defense of the law. Implying that the state of Ohio will just buckle-in to the big bully’s demands, and the citizens of Ohio dare not have a say-so.

As if drug companies can hold our health hostage and demand outrageous ransoms. As if big PhRMA and big pharma can get away with paying off all of our patient advocacy groups like NAMI, that gets 75% of its funding from pharmaceutical companies, and all of Washington DC. As if pharmaceutical companies can charge ten times more for drugs in the United States than Europeans pay, and Americans aren’t allowed to negotiate. If that is truly so, then only the richest people will ultimately be able to pay, and the rest of us will be out of luck. We aren’t really going let that happen, are we?

Regardless of all that pressure from drug companies and deceptive TV ads that bleed money – confusing ads that indoctrinate us to hate and fill our hearts with prejudice, dread and fear, keeping us down like spineless little mice – an industry that pollutes our communities with their opioids and got Congress to pass a law to ease up on the DEA investigations of how they do it — I’m still voting yes, because voting yes is the only way to get them to stop killing us.

With money to burn, drug companies dominate our nightly dinnertime news hour with ads for very expensive drugs that hardly anyone needs and few can afford. As if we don’t have doctors. Since when do drug companies prescribe the drugs? 

Having to pay multiple times the price people pay in Europe for the same prescription drugs is a shameful social travesty and a betrayal of public trust. Yet we’ve been standing aside while they make huge profits and waste our healthcare dollars. 

I’m voting Yes on Issue 2, to start the revolution. Taxpayers can save an estimated $400 million per year on state-bought drugs alone. The state of Ohio is a huge pharmaceutical buyer and we deserve the same lower price that the Veterans Administration pays.

If Issue 2 wins, then other states will follow suit, insurers will demand the same price, and we will be shaving billions of dollars off of the unsustainably high cost of healthcare in this country today.

But what I look forward to most of all, is the drying up of the huge pharmaceutical lobby pool, when they don’t have so much money to splash around.

Wouldn’t it be great if We The People could get our elected representatives back?

2018 Rate Review

New for 2018, Marketplace rates for children will rise 20% to 53%, on top of the additional average 20%-30% rate increase insurers in Ohio demand in 2018.

Child rates in the past they have always been 63.5% of the adult base rate until the age of 21. Next year, 0-14 will be 76.5% of the adult base rate, with ages 15 to 20 being 83.3% to 97% of the adult base rate.

2018. We all know how it’s going. We are supposed to feel lucky that we can at least still buy health insurance. And after what we witnessed in Congress this year, and how it could have gone, but for one vote, we know we’re damn lucky.

We were warned that rates would go through the roof this year. That’s due to the uncertainty of the government reimbursing insurers for CSRs, the uncertainty over the insurance requirement mandate, the uncertainty of a repeal, as well as the totally understandable (not), predictable, ever-rising, unsustainable, runaway medical and non-negotiable pharmaceutical cost factors, that alone amount to a 7% rate increase in 2018, along with the resumption of the ACA tax on premiums that was halted last year, and some increases in administration costs. We are braced for rates to going up 20 to 40% or more. Hands above our heads, they got us, we’ll pay!

The ACA, warts and all, has survived the Congressional guillotine, and the 6% of the U.S. population that comprises the individual insurance market is certainly grateful for another year of being able to buy health insurance.

But what a sneaky thing the child age rating hike is, which raises the rates for all children under the age of 21 by 20% to 53%. CMS snuck that in on December 16, 2016, just after Trump was elected. That, on top of all the “uncertainty,” the rising medical costs blah blah blah, 2018 is going to be a real doozy.

Which is why a typical family may see a rate hike of 29% for themselves, and 71% for their children.

Family in 2000 has been through it all

Take your typical Ohio family – say, John and Pam, who are 55. They have two kids who are 17 and 20. John is an independent contractor and earns $78,000. Pam is an adjunct university professor and earns $21,000. Together they make $99,000 before taxes, just over the 400% Federal Poverty Level that would qualify them for a health insurance subsidy. Their net income after taxes is $78,000.

Having to buy individual insurance, they chose Molina, because that was the only plan in which they could find doctors who would accept them as patients.

Toledo, Ohio is a closed town when it comes to doctors accepting new patients. When it became too costly in 2016, John and Pam had to give up their Medical Mutual PPO insurance and hence their ProMedica doctors that they had been going to for 20 years. Molina was one of the cheapest insurance plans they could buy. But they had to find new doctors, because their long-time doctors didn’t accept Molina insurance.

Mercy doctors were in the Molina network, and they were not as closed as ProMedica doctors.  That’s why they chose Molina over CareSource, another cheap plan, but one with a 90% inaccurate provider network, a network that supposedly included ProMedica doctors, but not really. (ProMedica, when last checked, had only one primary care family practice doctor accepting new patients, but you’d have to call back in a month to schedule an appointment, which supposedly would be scheduled for three months after that.*)

If they had made just two thousand dollars less (see Kaiser subsidy calculator here), John and Pam would have qualified for a $3,334 subsidy this year (undoubtably it would be more than $6,000 in 2018 because the SLCSP which is tied to the subsidy may be 20-30% more, in tandem with the rest of the plans; see rate increases below.) The subsidy would have reduced their health insurance premiums to 10% of their gross income for a silver plan, but alas, they make too much money to qualify.

John and Pam chose a gold plan with a lower deductible because they couldn’t afford the risk, just in case, of having to come up with $7,500+ to meet the deductible before the insurance would kick in.

With an increase of over $6,000 in 2018 for health insurance, their tightest budget, cutting down on food, recreation, transportation and clothing, exceeds their net income. Forget about helping with their kids’ education or even saving for their own retirement, which is coming in 10 short years – in 2018, they are going into credit card debt on their necessary expenses just to be able pay for health insurance.

As it was, in 2016 John and Pam paid 22% of their net income on health insurance, $17,448, at $1,454/month. It was a lot more than they were paying just a few years before. An affordable and reasonable percentage, in keeping with the spirit of the ACA, would be 13% of their take-home, or 10% of their gross. John and Pam make more money than most families in Toledo, but to have 22% of their net income going to pay for health insurance really hurts.

In 2016, John and Pam’s rates were $554.50 each per month, and the kids’ rates were $172.62 each.

But next year, in 2018, John and Pam’s health insurance will go up 39%! It will surpass housing as biggest chunk of their budget, becoming a whopping 31% of their take-home income, $24,240 for the year; $2,040/month. The astronomical but necessary expense squeezes out any money that could ever have been saved for retirement, which they need to fund, and eliminates any possible budget they may have hoped for to help their kids with higher education expenses.

While John and Pam’s health insurance is going up 29%, health insurance for their kids goes up 71%. The family’s health insurance premiums next year will cost $6,792 more than last year!

In the midst of uncertainty and rising medical and unnegotiable pharmaceutical cost factors, what a sneaky rate hike this children’s age rating hike is, and what a scary thing it is for families like John and Pam’s. Thanks, elected officials, for looking out for our best interests. Maybe it’s time to stop the killing and let everyone in on Medicare, expanded and improved.

OTHER OBSERVATIONS

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Toledo is down to five insurers for 2018, listed on the left -- Ambetter, CareSource, Molina, Medical Mutual HMO, and Paramount.

2018 Rate Review Observations

Anthem is the only insurer right now in 19 Ohio counties, and in 2018 they will be exiting the Ohio individual market, except for one teeny tiny county, Pike, for a non-exchange plan that probably has 5 members, just so they can keep their foot in the door and not be banned for five years in case they want to come back. Awe.

Anthem has about 18% of the individual market in Ohio, and they insure millions of Ohio corporate and state workers. 40,000 individuals are presently covered by Anthem, and 10,000 people may not be offered any individual plan next year as a result.

In Toledo, Anthem has the worst, smallest provider network, and it was 66% inaccurate. It is highly expensive, and went up quite a bit last year.

Anthem more than tripled their premiums in seven years, just like Medical Mutual did, who left hanging an estimated 100,000 people covered by their PPO plans, completely exiting  and extinguishing the sale of PPO’s in the individual market,  thus eliminating the only national network plan sold to individuals in Ohio. Last year two insurers covered nearly 50% of the Ohio individual market, and now they are gone.

Also gone this year is United Healthcare and Aetna, so just like that, our four largest insurers of the individual market are gone from the individual market, and Ohio let them, even rewarding the insurers with our state employee insurance business. Ohio either has no business sense, or our state really doesn’t care whether or not 300,000 Ohioans can buy insurance in the individual market.

Four things that Ohio can do to mitigate this healthcare crisis:

1.

Ohio should do what New York is doing this year, and ban insurers who leave the exchange from any future participation in public programs such as Medicaid.

Governor Cuomo announces aggressive actions to protect access to quality affordable health care for all New Yorkers  New York State website
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2.

Ohio should propose a Medicaid buy-in for anyone in the state, like the plan that Nevada’s legislature just passed for it’s citizens. After all, our commercial insurers in the individual market (Anthem, Medical Mutual, United Healthcare, Aetna) have been replaced by Medicaid insurers (Buckeye Ambetter, CareSource, Molina), and since all of Ohio is covered for Medicaid, it makes sense that these insurers can also cover all of Ohio for the individual market, and with great ease.

Nevada’s legislature just passed a radical plan to let anybody sign up for Medicaid  VOX
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VOX

3.

Ohio should pass an emergency “any willing provider” law so that citizens can take their insurance dollars to any provider willing to accept them and the payment. At an average of 80% inaccuracies in our provider networks, have the worst that have been reported in the entire country! It’s only civilized that Ohio gives us an”any willing provider” law.

4.

Oscar Insurance Corporation of Ohio, a new insurer for Ohio this year, should cover all the counties that Anthem has left hanging.

But they won’t be covering even one of them. It comes to Ohio to set up shop with Cleveland Clinic in the five counties around Cleveland.

It’s a perfect example to show why market-driven health insurance does not jive with societal needs, and it never will.

Click the photo to visit Oscar’s News page

(Dream on, hoping for a private, for-profit insurance industry to voluntarily go into 19 counties for the business of a mere 10,000 people who won’t otherwise have insurance, when the company can get the same business by simply marketing to the east side of Cleveland. But for some reason, the for-profit, so called “free market” health insurance model persists. And it has nothing to do with what is best for our country.)

5.

Here’s something the federal government can do: Open up the D.C. Exchange to people without an option, as per U.S. Senator Claire McCaskill’s proposal.

McCaskill proposes expansion of DC exchange Columbia Daily Tribune, May 18, 2017
Check out this video clip on McCaskill’s Facebook page from June 9, where she asks the Senate for a hearing on the secret health insurance plan that the Republicans are going to impose on Americans without any discussion with Democrats or the public!

The D.C. Exchange sells insurance for everyone in the country, that is, everyone who is a member of Congress or their staff. I have researched the plans and found that they are really inexpensive compared to what is sold in Ohio. Moreover, it’s quality PPO insurance with national provider networks.

At one time, the ACA was going to have just one exchange for the entire country, like this exchange in D.C. But then the insurers got their mitts on the shaping of the ACA. They sliced it up into hundreds of different state and county plans. Four short years later, insurers are leaving, and hundreds of counties will have no insurance option. It seems logical to open up the D.C. exchange, for everyone. What would be wrong with doing that?

Click on the photo to visit the DC Health Link

On a final note, the chart below shows the three largest insurers in Ohio, from a report made to the state of Ohio by the actuarial company, Milliman, in 2011. I added to the original chart in light blue, to show the individual rate increases since 2010. (The dark blue along with the red and green show the 2010 rates.)

With the withdrawal of Anthem, none will be in the individual market next year! Our three biggest insurers in the individual market in 2010, gone!

It’s no wonder, because our regulators let their rates go up over 300% in 7 years, while the rates for the group plans went up only a total of 30%. Wow. You’d think that all the new members of these plans had leprosy. I hope they are cured, at least.

Divide, divide, divide. Divide and subtract some more! The huge free market health insurance system is so close to knocking off those 23 million people who just don’t fit in their money-making calculations.

The Wild Wild West of American-style Pharmaceuticals

Pierre scans July 20160012

This is my great great grandfather’s photo of the Kickapoo Indian Medicine Company.

The Kickapoo Indian Medicine Company, of New Haven, Connecticut, sold “patent medicine” before they had patents for medicine. They sold snake oil when it was the cure-all. They weren’t really Indian. Kickapoo Medicine was often laced with alcohol, morphine, opium, or cocaine.

Fast forward to 2017. The shenanigans continue. Many mass market brand-name drugs that are nearing the end of their patent and even after the patent is over are being given orphan status. Orphan status allows the drug company to have a longer period of exclusivity on a drug and raise the price even higher than it was before.   Drugmakers Manipulate Orphan Drug Rules To Create Prized Monopolies     see also Orphan Drugs Lookup  new on Feb 10: Grassley launches inquiry into orphan drugs after KNH investigation

Meanwhile, generic drug manufacturers, taking advantage of patents that are no longer exclusive, have colluded with other drug manufacturers who make the same drug to raise their prices as much as 8,000%. A lawsuit is pending.   Alleged Scheme To Fix Generic Drug Prices Started At Dinners And ‘Girls Nights Out’

And now Trump wants to loosen regulations to encourage start-ups and get drugs to the market faster —  TRUMP’S PLAN FOR LOWERING BIG PHARMA DRUG PRICES COMES AT A HIGH COST

YEE-HAW!

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Provider Network Complaints Get Buried

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The good news is, I finally received some of the provider network consumer complaints that I asked for from the Ohio Department of Insurance.

The bad news is, for many of the complaints, we don’t get to know the outcome because the Ohio Department of Insurance kicks the complaint over to another department, and they make it confidential. The following are paragraphs from the Ohio insurance department’s closing letters for various provider network complaints:

Due to this error we are referring our findings to another division within the Department for further review. Please be aware that investigations by this division and the records pertaining to these investigations are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be opened on the matter or if an active case investigation is opened and the status of the investigation.
Based upon our review of the facts and circumstances presented, we determined that CareSource provided you inaccurate information regarding their provider network. The Department is also concerned about the likelihood that additional members have received inaccurate network information as well. Therefore, this matter has been referred to another division in our agency for investigation.
Due to incorrect information provided to you by Buckeye, we have forwarded our findings to another division within the Department for further review. Please be aware that investigations by this division are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be open on the matter you reported or if an active case investigation is opened and the status of the investigation.
Caresource did not initially administer the claim in accordance with the terms of your policy; therefore, we have forwarded our findings to another division within our Department for further review. Please be aware that investigations by this division and the records pertaining to these investigations are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be opened on the matter you reported or if an active case investigation is opened and the status of any investigation.
We have forwarded our findings to another division within our Department for further review. Please be aware that investigations by this division are confidential by law. Consequently, the Department will not be able to provide you with any information as to whether an active case investigation will be opened on the matter you reported, or the status if an investigation is opened.

What is the law that they claim prevents them from revealing the status or results of the investigation? The new provider network rules they put into place this year. They wrote in a clause that gives them the power to keep investigations confidential.

http://codes.ohio.gov/oac/3901-8-16

(2) All documents provided to the superintendent under paragraph (G) of this rule shall be considered work papers of the superintendent that are subject to section 3901.48 of the Revised Code and are confidential and privileged and shall not be considered a public record, as defined in section 149.43 of the Revised Code. The original documents and any copies of them shall not be subject to subpoena and shall not be made public by the superintendent or any other person, except as otherwise provided in section 3901.48 of the Revised Code.

Clever!  So all of our provider network complaints get buried. Companies get to keep doing this, because the Ohio Department of Insurance doesn’t care. They reward them instead, with confidentiality. And after two years, they destroy the original complaint, buried, burned, deleted.

I told you they are run by the insurance guy!

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Related: Ohio Citizen Rate Review Provider Network Survey, Summer 2016

Related: Passing the Buck: My letter to complaint examiner

Medical Mutual Complaint, Example 6 – Accountability

"0" Premium before tax credit. November 27, 2015 credit shown for $62,000 income
$0 Premium before tax credit. Sign me up!

During last week’s preview week on healthcare.gov, Medical Mutual  offered duplicate plans, same name but one serial number off from other plans, that cost nothing. Zilch. $0. And then I couldn’t believe how much my premium was going up on the mirrored plan that was not $0. What a great deal – those $0 plans! So I called Medical Mutual to ask more details about the $0 Premium before tax credit offerings on healthcare.gov, because the $0 plan was clearly offered to me. These are direct quotes from Naomi in the Medical Mutual sales department on October 27:

You have to talk to the Marketplace. I don’t see the plan. I can’t look it up by plan number. You just popped up on the line and I answered your call.

I cannot look up plans by plan number, you have to go back to the Marketplace. Marketplace is administrating the plan.

Your premium went up because the federal government regulates that and they increased everyone’s premium.

You’re asking me to look up a plan on a different company’s website that I can’t see.

You want me to have all the answers as to why there is a free plan on the healthcare.gov website and it is offered to you.

We don’t have info on the plans offered on healthcare.gov, you have to go to them. It’s a different entity.

I can’t give you false information. I can but I’m not going to do that.

I cannot look up a policy that we do not offer.

It’s federally facilitated, different from Medical Mutual.

I can’t answer your questions because they are offered through healthcare.gov.

Sounds like it’s for medicaid.

We have no information on it. Nobody answers questions about plans on healthcare.gov. It’s through the government. You need to contact healthcare.gov because it’s offered through healthcare.gov. For this plan you have to call healthcare.gov.


When I spoke to Stacey at healthcare.gov on October 27, he duplicated everything I did on his screen and came up with the same results I was getting and these are his direct quotes:

I thought that was their job. (He said when I told him Medical Mutual told me I had to ask healthcare.gov about their plans.)

I would think that, and I’m putting them side by side, they are identical.

I don’t know why it says “child” because it covers adults and children.

This plan has costs and this doesn’t. I don’t understand, I really think that Medical Mutual should have been able to tell you some basic information.

I see this plan and all the details that it consists of, and it would seem you would pay “0” dollars.

This seems like the one to get, and when its says premium before tax credit is “0” you don’t even need a tax credit.

It’s like a trick, like smoke and mirrors.

It is very bizarre. They are nearly identical to the other plan, they are only one number off in the plan ID so I understand your concern.

I have never really experienced this in this way.

It seems as if it is supposed to be “0” dollars, or it is a trick.

It’s ridiculous, it’s their plan, it’s their company and they won’t talk to you about it.

Here’s a phone number you can call, Ohio Department of Insurance, let them know what is going on. Let them know what we discussed, that I see the same thing you see.


So I took healthcare.gov’s advice, and after speaking with the Ohio Department of Insurance, I filed a consumer complaint against Medical Mutual for pricing and accountability and false advertising.

Page one of my consumer complaint, no. CSD-0034217
Page one of my consumer complaint, no. CSD-0034217

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